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Maximum collegiality: Improvement of physicians` professional efficiency and quality of life by creating (informal) “backup-squads” in hospitals

Background: Lack of time in hospitals

Everyday life as a doctor is characterized by foreign determination. We have the feeling as if our work can never be accomplished. We could work 24/7 and still feel like we have not really cared for all our patients. At the same time, we are subject to further obligations beyond direct patient care: Administration, documentation, research, student education, and special tasks.

These additional fields of activity are usually just as necessary as relevant, exciting, and in many cases, career-enhancing. Unfortunately, due to the density of obligations and urgency in patient care, we have little time to devote ourselves fully and satisfyingly to these tasks in the official working hours. In consequence, we tend to them at night, on weekends, during the holidays, or somehow between the treatment of the patients. It is no wonder that the quality of execution and job satisfaction are impaired. We, therefore, increasingly see additional tasks as a burden.

On the other hand, we daily identify structures and processes in the clinical routine that are not optimal. On many occasions, we have ideas on how to improve the hospital for the benefit of the patients, the personnel, or ourselves with leaner and more efficient measures. But it is not easy to get all our ideas going because change in hospitals usually is a highly complex project. Those projects are prone to failure if not carried out systematically and under consideration of the essential principles of professional change management. Even worse, we rarely have regular time for sustainable change management.

So, are we as physicians fighting a losing battle by not having enough time for administration, documentation, research, student education, and specials tasks next to the pressing matters of patient care?

We vehemently oppose this fatal conclusion and instead advocate pooling our resources, strengths, and capabilities with some selected colleagues. The joint forces facilitate even large projects in the face of the heavy clinical workload.

Unconditional team support: The "backup-squad."

Founding a small team within the team – we call it backup-squad – has proven to generate some valuable space for each participating colleague. A backup-squad is an (informal) team that consists of 2-4 colleagues who keep each other’s backs. The group should be made up of colleagues whose medical competencies and tasks overlap in large parts so that everyone can fully step in for the other. Now, team members can keep each other free for a certain period, e.g., 1 hour, in phases in which, according to experience, the density of tasks in the clinical routine is slightly lower than in peak times. Depending on the needs and capabilities, these backup times can be scheduled daily or at longer intervals. Each team member can now withdraw for the agreed period and devote himself to tasks beyond immediate patient care during working hours while the team is fully covering his or her clinical duties.

To get something straight right off the bat: We are not naïve and are aware of the limitations of our unorthodox suggestion. It is, of course, not possible to create backup-squads in every discipline and every hospital to the same extent. Thus, our approach is more suitable for some clinics than to others. For example, a surgeon cannot interrupt his operation because he is supposed to represent his colleague on the infirmary for the project time.

Nevertheless, we are convinced that the general idea of a backup-squad will be functional to a useful degree in every hospital and every department and even in surgery. Scenarios can be designed for every specialist in every hospital that allow for the application of our model. Eventually, its advantages for patients, the hospital, and, last but not least, doctors and nurses can be skimmed. Thus, the concept of a backup-squad presented here should be regarded as a basic recipe for an (informal) team-building measure that – of course – requires customization to fit any individual situation.

200 hours for special projects

Probably the relief is not perceived as helpful at the beginning as it really is. Because the plethora of additional tasks could have grown so much over the years that an hour a day for their processing hardly leads to a visible reduction of these responsibilities in the early phase. However, an hour a day totals 5-7 hours a week, which is probably an increase in dedicated weekly project time of 500%. With assumed 200 working days per year, the project time will sum up to 200 hours per year. We assume that a dedicated period of 200 hours most likely is considerably more than most doctors currently spend to introduce systematic optimizations in the hospital, to work on scientific projects, or to implement measures that directly serve their careers.

However, as soon as a large part of the legacy tasks has been dealt with, the project time can be devoted to initiating innovative change projects, exciting research projects, or high-quality teaching of students, nurses, and colleagues. The backup-squad team members have now moved from a reactive, passive, and foreign-determined role to an active, shaping, self-determined position, which can lead not only to a significantly increased quality of life but also to tremendous career advantages.

The structure of a backup-squad

You should refrain from setting up hierarchy levels in the backup-squad.This team should consist of equal partners, united by their shared interest in taking unusual paths to ascertain the well-being of patients, the long-term prosperity of the hospital, and their careers. The connecting element of the team members is the reciprocity principle. Each team member benefits from the reliability of his colleagues and will, therefore, try to return this reliability himself.

Also, there is the possibility to distribute tasks according to the interest and skills of the team members within the backup-squad. For instance, the (small) organizational duties can be assigned to different team members: conducting work reports to the medical director or the board of the hospital, internal and external communication measures, the definition of timetables/backup times, and more.

After the establishment of the backup-squad model, the consolidation of mutual trust, and the reduction of personal legacy tasks, the team members can even move on to splitting their special projects in hospital organization, research, or education among themselves. Perhaps one team member is more interested in research tasks, while the other is more in to teaching and further vocational training for colleagues or nurses. A third member, on the other hand, may be more focused on process optimization and management. If the backup-squad makes appropriate shifts of responsibilities internally, but the team members still involve each other in all the projects, synergies, efficiency gains, and bundling effects can be freed up, from which all members benefit to a considerable extent personally and professionally.

Acceptance and legitimation

The life-cycle of the backup-squad should be set at least six months. It takes this period to make the model a habit for the team members and the rest of the department. The most crucial prerequisite of an (informal) backup-squad is the absolutely unrestricted execution of all routine tasks even when a team member is missing in the clinical care. This upkeep of top medical quality requires the highest level of reliability, sensitivity, and competence of the team members.

Hence, although the aim should be to get time for project work daily and as regularly as possible and despite the approval of the clinic management (see below), there is no unconditional right to regular “exemption.” Instead, all team members should always give the highest priority to clinical requirements and refrain from project work on days when clinical life does not allow. Especially in the first few weeks, colleagues, supervisors, and nurses will most likely pay close attention to whether the new division of labor will impair healthcare. In this sensitive initial phase, even minimal failures in patient-care can massively damage the acceptance of the model.

After the successful introduction of the first optimization measures, from which all stakeholders of the hospital should benefit, the acceptance of the model by colleagues, who will certainly envy the backup-squad, will increase. We, therefore, suggest spending the first free project time in obviously needed optimization measures for the benefit of as many people in the hospital as possible. The first projects should aim to add high measurable value for patients and colleagues rather than taking care of straight personal career-enhancing activities to prove the trustworthiness of the backup-squad.

Also, the support of the board or the department’s medical director is crucial for the success of a backup-squad.The processing of administration, documentation, research, teaching, or optimization projects during the usual clinical routine must have been made known to the Medical Director and approved by him. Otherwise, it is easy to falsely create the impression that members of the backup-squad are taking time off for “private projects” during working hours, even if all activities are exclusively dedicated to improving patient care or the hospital’s economic prosperity. People generally suspect the worst. In addition, a supervising instance is handy for the group in the vast majority of cases.

Risk assessment and risk mitigation

The ultimate goal should be to create multiple backup-squads within the department; every doctor should be a member of a backup-squad.The individual teams should communicate with each other as transparently as possible. In this way, the backup-squads can support each other, e.g., during vacation periods, during congresses, or in the event of a high level of sick leave. The basic supporting concept of the backup-squads should be spread in the entire hospital, which creates even greater value and may lead to a cultural transformation.

The formation of self-proclaimed elites or isolated or isolating groups with subsequent destructive over-competition poses a risk to this model. This risk should be addressed through transparent communication between the groups and the mediation of the board or the medical director.

On the other hand, it is undoubtedly far more detrimental and no longer just a risk, but in many places a reality, that doctors in the hospital are more or less left alone in designing their careers. They feel the existential need to hold or aggressively extend their position in the current healthcare system in many places and, thereby, not always act for the benefit of the hospital.

The inherent risks of the backup-squad formation thus need to be weighed up against the effects of this “lone fighter”-behavior. After all, declining applicant numbers of physicians and nurses and a manifest shortage of specialists already reflect the dysfunctionality of the current leadership and personnel development in healthcare systems in many countries.

Project management and organisation

The backup-squad should develop a plan as early as its foundation, which includes all the tasks and projects for which the expected project time is to be used. This will require a meeting of all team members to frankly present the individual obligations such as the nature and number of existing tasks, research projects, teaching activities, and special projects, including each supposedly necessary time (kickoff-meeting).

Now, the backup-squad team members can assess the point of time when the individual exemption can be used not only to accomplish the respective personal tasks but to work on joint projects.

Appropriate project management tools help to set goals, milestones, and endpoints for the individual and joint projects. Suitable evaluation criteria should be defined to measure the work of the backup-squad qualitatively and quantitatively. Unsolicited, regular reports for the board or the medical director promote the acceptance of the model and ultimately serve as a guideline for the team members. In order to increase the approval of the backup-squad, positive results should be systematically communicated within the hospital and, in some cases, even externally.

Regardless of how deep and resilient the relationship between the team members of the backup-squad is, the exemption times should be logged and evaluated quarterly. Even the strongest friendships suffer when there are significant inequalities in the exemption periods, also if they originated most likely unintentionally and resulted from the hospital’s clinical demands. A team member should take over the logging, evaluation, and distribution of the times among the team regularly. Possible imbalances could be compensated in the next interval, which in the long run, maintains the motivation to support the team members in the squad.


The establishment of a backup-squad could leverage synergies by the close collaboration of physicians. The enhanced team spirit could eventually lead to a stronger identification of the staff with the hospital`s values and goals. The shift of special-tasks beyond patient care from leisure time to working hours will lead to a significantly improved quality of life and, consequently, to increased clinical performance. Research and education are finally given an adequate place in the daily work, which can also lead to an improvement in quality in these areas.

The identification of process or structural optimizations, as well as their sustainable implementation, will result in improved patient care, a better economic result of the hospital, and an increased employer quality. The professional and transparent introduction of this innovative model can address the risks of over-competition within the department or the formation of isolated and isolating groups.


The creation of backup-squads is a sophisticated measure that should be carried out with great sensitivity as well as with a high level of professionalism. The risks are too high that opposing forces around the hospital will sabotage this model. Moreover, there is the risk that the absence of quick visible and noticeable effects for the team members endangers their motivation to support each other.

Thus, Hannover-Medical.Management provides a management manual that includes a step-by-step-instruction to improve the success rate of this promising model significantly.

In detailed courses (online and on-site), we not only present the model but the required project management tools to implement the team formation properly in your hospital. This holistic approach ensures a smooth inauguralization of this unorthodox, yet systematized collegiality. We illustrate the possible application in the Hannover-Medical.Management Manual, that you can download here now.